Nondiagnostic Rate Research Articles

Factors Influencing the Reliability of Thyroid Fine-Needle Aspiration: Analysis of Thyroid Nodule Size, Guidance Mode for Aspiration and Preparation Method

Objective: We aimed to clarify the influence of ThinPrep preparation, nodule size and guidance mode on the accuracy of thyroid fine-needle aspiration (FNA). Methods: A total of 1,240 thyroid FNAs were reviewed and 489 cases with histological correlations were enrolled in this study. Results: Of the 489 total cases examined, 101 were processed with both ThinPrep and conventional preparation and 388 entirely with ThinPrep. The overall nondiagnostic rate, sensitivity and accuracy of FNA were 2.0, 91.0 and 89.4%, respectively. The cases with a preoperative ultrasound (n = 469) were grouped according to nodule size. The nondiagnostic rate, sensitivity and accuracy of FNA did not differ significantly with nodule size (p1 = 0.339, p2 = 0.179, p3 = 0.119). A total of 101 resections were performed with palpation-guided FNA and 388 were performed with ultrasound-guided FNA. The nondiagnostic rates, sensitivity and accuracy of FNA were similar in these two groups. Conclusions: The ThinPrep technique is a valid method for thyroid FNA and is effective for thyroid nodules ≥0.5 cm. The reliability of FNA results is not reduced with larger nodules. The use of palpation-guided FNA for palpable solid nodules is also effective.

MP44-16 PREDICTORS OF NON-DIAGNOSTIC RENAL MASS BIOPSY

You have accessJournal of UrologyKidney Cancer: Evaluation and Staging II1 Apr 2015MP44-16 PREDICTORS OF NON-DIAGNOSTIC RENAL MASS BIOPSY Michael Blute, Joel Prince, Eric Bultman, Louis Hinshaw, Anna Drewry, Sara Best, Fred T. Lee, Timothy Ziemlewicz, Meghan Lubner, Fangfang Shi, Stephen Y. Nakada, and E. Jason Abel Michael BluteMichael Blute More articles by this author , Joel PrinceJoel Prince More articles by this author , Eric BultmanEric Bultman More articles by this author , Louis HinshawLouis Hinshaw More articles by this author , Anna DrewryAnna Drewry More articles by this author , Sara BestSara Best More articles by this author , Fred T. LeeFred T. Lee More articles by this author , Timothy ZiemlewiczTimothy Ziemlewicz More articles by this author , Meghan LubnerMeghan Lubner More articles by this author , Fangfang ShiFangfang Shi More articles by this author , Stephen Y. NakadaStephen Y. Nakada More articles by this author , and E. Jason AbelE. Jason Abel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1558AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Percutaneous renal mass biopsy (RMB) may be used to guide treatment decisions in small renal masses (SRM). However, approximately 15% of patients receive no benefit from RMB because findings are non-diagnostic. The objective of this study is to identify patient and tumor characteristic s that are associated non-diagnostic RMB. METHODS After IRB approval, data were reviewed for all RMB for masses ≤7cm from 2000 to 2014. Univariable and multivariable analysis was performed to identify predictors of indeterminate RMB including: imaging modality, type of biopsy, laterality, proximity to adjacent organs, tumor diameter, presence of radiologic enhancement, fat, calcification, necrosis, or cystic features, position within the kidney, body mass index, and skin to tumor distance. RESULTS In 83/565 (14.7%) overall and 72/413 (17.4%) with SRM ≤4cm, the biopsy findings were non-diagnostic. There were no differences in age, BMI, Charlson comorbidity score, or gender between diagnostic and non-diagnostic biopsy patient cohorts. Independent predictors of non-diagnostic biopsy overall included: cystic features, radiologic enhancement <20HU, tumor diameter, and skin-to-tumor distance (table). A total of 83 masses were classified as cystic, including 4/1/10/18 Bosniak category 2/2f/3/4 lesions. The non-diagnostic rate for RMB of cystic masses was 39.8%. Of 38 tumors with ≤20HU enhancement, non-diagnostic findings were noted in 16 (42.1%) including 9 pseudo-enhancing and 7 non-enhancing masses. Median skin-to-tumor distance was 10 cm (IQR 8.5 cm – 11 cm). Among 52 tumors with a skin-to-tumor distance ≥13 cm, 14 (26.9%) of biopsies were non-diagnostic. In patients with initial non-diagnostic biopsy, repeat biopsy non-diagnostic rate was not different from initial biopsy, 20.8% vs. 14.7%, (p=0.38). There was no there was no association between radiologist or pathologist experience and non-diagnostic rate, (p=0.76, 0.67). In 462 procedures where a resident or fellow was involved, there was no difference in non-diagnostic rate, p=0.80. In 7/565 (1.2%) patients, hospital admission was required after RMB for biopsy complications. CONCLUSIONS Non-diagnostic RMB is more common in masses that are cystic, have radiographic enhancement ≤20 HU, diameter ≤4 cm, or skin to tumor distance of ≥13 cm. These criteria can be used to improve patient selection for RMB. Multivariate Analysis of 413 renal masses >= 4cm for predictors of non-diagnostic biopsy Variable OR (95% CI) p-value Axial diameter per cm 0.59 (0.39-0.90) 0.01 Cystic features 4.85 (2.42-9.72) <0.0001 Radiographic enhancement <= 20HU 3.57 (1.49-8.52) 0.004 Skin to tumor distance >= 13cm 2.62 (1.17-5.85) 0.02 © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e532-e533 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Blute More articles by this author Joel Prince More articles by this author Eric Bultman More articles by this author Louis Hinshaw More articles by this author Anna Drewry More articles by this author Sara Best More articles by this author Fred T. Lee More articles by this author Timothy Ziemlewicz More articles by this author Meghan Lubner More articles by this author Fangfang Shi More articles by this author Stephen Y. Nakada More articles by this author E. Jason Abel More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

In vivo, percutaneous, needle based, optical coherence tomography of renal masses.

Optical coherence tomography (OCT) is the optical equivalent of ultrasound imaging, based on the backscattering of near infrared light. OCT provides real time images with a 15 µm axial resolution at an effective tissue penetration of 2-3 mm. Within the OCT images the loss of signal intensity per millimeter of tissue penetration, the attenuation coefficient, is calculated. The attenuation coefficient is a tissue specific property, providing a quantitative parameter for tissue differentiation. Until now, renal mass treatment decisions have been made primarily on the basis of MRI and CT imaging characteristics, age and comorbidity. However these parameters and diagnostic methods lack the finesse to truly detect the malignant potential of a renal mass. A successful core biopsy or fine needle aspiration provides objective tumor differentiation with both sensitivity and specificity in the range of 95-100%. However, a non-diagnostic rate of 10-20% overall, and even up to 30% in SRMs, is to be expected, delaying the diagnostic process due to the frequent necessity for additional biopsy procedures. We aim to develop OCT into an optical biopsy, providing real-time imaging combined with on-the-spot tumor differentiation. This publication provides a detailed step-by-step approach for percutaneous, needle based, OCT of renal masses.

&lt;em&gt;In Vivo&lt;/em&gt;, Percutaneous, Needle Based, Optical Coherence Tomography of Renal Masses

Optical coherence tomography (OCT) is the optical equivalent of ultrasound imaging, based on the backscattering of near infrared light. OCT provides real time images with a 15 µm axial resolution at an effective tissue penetration of 2-3 mm. Within the OCT images the loss of signal intensity per millimeter of tissue penetration, the attenuation coefficient, is calculated. The attenuation coefficient is a tissue specific property, providing a quantitative parameter for tissue differentiation. Until now, renal mass treatment decisions have been made primarily on the basis of MRI and CT imaging characteristics, age and comorbidity. However these parameters and diagnostic methods lack the finesse to truly detect the malignant potential of a renal mass. A successful core biopsy or fine needle aspiration provides objective tumor differentiation with both sensitivity and specificity in the range of 95-100%. However, a non-diagnostic rate of 10-20% overall, and even up to 30% in SRMs, is to be expected, delaying the diagnostic process due to the frequent necessity for additional biopsy procedures. We aim to develop OCT into an optical biopsy, providing real-time imaging combined with on-the-spot tumor differentiation. This publication provides a detailed step-by-step approach for percutaneous, needle based, OCT of renal masses.

Ultrasound-Guided Thyroid Fine Needle Aspiration Biopsy—The Way Forward

Dear Editor, I read with great interest the recent article published in the Annals of Academy of Medicine Singapore entitled, ‘Surgeon-Performed Ultrasound-Guided Fine Needle Aspiration Cytology (SP-US-FNAC) Shortens Time for Diagnosis of Thyroid Nodules, Ann Acad Med Singapore 2014;43:320-4’. Indeed, ultrasound-guided fi ne-needle aspiration (US-FNA) is an exceptionally valuable and simple approach for the diagnosis of thyroid nodules, and has a much higher sensitivity and specifi city compared to conventional palpation-directed biopsy techniques. Nonradiologists (surgeons, endocrinologists or sonographers) are also increasingly involved in US assessment and USFNA of thyroid nodules, which translates into shorter waiting time for the patient and greater patient satisfaction. Many recent epidemiological studies have shown the rapidly rising incidence of thyroid cancers despite stable low mortality rates of such cancers.1,2 Most of the increase was contributed by the rise in the diagnosis of small papillary thyroid cancers, which generally have an indolent course and a favourable long-term prognosis. Intriguingly, Brito et al1 have recently proposed that overzealous use of imaging and biopsies by clinicians contributed to this trend. Hence, many professional bodies have strived to produce guidelines to aid clinical decisions in the selection of thyroid nodules for US-FNA, recommending only nodules with suspicious ultrasound characteristics be biopsied.3 Although no single ultrasound characteristic can confi dently predict malignancy in the assessment of thyroid nodules, the presence of several suspicious ultrasound features generally provides excellent accuracy in such predictions. The authors in the paper quoted a non-diagnostic rate of 30% in their institution, which was partly attributed to the initial lack of experience in this procedure. In our experience, the presence of a cytotechnologist on-site examining the specimen have been shown to improve diagnostic adequacy through improved sampling, and have largely contributed to a consistent nondiagnostic rate of below 10%. One of the main advantages of on-site assessment is that it allows additional material to be aspirated if the sample is insuffi cient or if material is needed for ancillary tests.4 Furthermore, the presence of a trained biomedical scientist enables good quality preparations to be made. The sampling of nodules with large cystic components could have also accounted for the authors’ higher non-diagnostic rates. The cystic component of the thyroid nodule has been shown to be an independent predictive factor for non-diagnostic specimens.5 However, repeat US-FNA often provides an adequate specimen and should be the standard approach to such nodules, given their potential risk of malignancy. In summary, US-FNA is an excellent modality for the assessment of thyroid nodules. However, clinicians should be aware of the pitfalls of over-diagnoses of such nodules. Non-diagnostic FNAs remain a signifi cant challenge in the evaluation of thyroid nodules and should be communicated with the patient, especially if the nodule in question is particularly cystic. Lastly, the presence of ancillary on-site support has been shown to increase sampling adequacy and should be employed whenever possible.

Improving the results of pancreatic endoscopic ultrasound-guided fine needle aspiration in daily practice: keep it simple.

Improving the results of pancreatic endoscopic ultrasound-guided fine needle aspiration in daily practice: keep it simple.

Comparison of two different standards of care in detecting malignant thyroid nodules using thyroid fine-needle aspiration.

The aim of the present study was to verify the optimal method to obtain enough fine-needle aspiration (FNA) materials for detecting thyroid malignancy. A prospective study was performed by comparing two different regional standards of care. In one group a traditional FNA method mainly used in Asian countries, including China, was performed in which a single pass of a 22-G needle was applied with or without aspiration. In the other group, the method mainly used in Western countries was performed in which three passes of a 25-G needle with non-aspiration were undertaken for thyroid nodules. The study included 718 thyroid nodules from 695 patients. These nodules were allocated for three different methods of performing thyroid FNA. There were 332 thyroid nodules subjected to the traditional Asian FNA method using a 22-G needle with aspiration for 142 nodules and non-aspiration for 190 nodules. FNA using the Western method was performed with three passes of non-aspiration using 25 G for 386 nodules. All the FNAs were performed with the guidance of ultrasound. The components of the nodules were documented. All the samples were reported using the Bethesda System for Reporting Thyroid Cytopathology. Among the 22 G group, the non-diagnostic rate in the aspiration group was as high as 76.76%, which was significantly higher than 44.21% in the non-aspiration group (P<0.01). For the non-aspiration group, the non-diagnostic rate in the 25 G group was 34.97%, which was significantly lower than 44.21% in the 22 G group. In general, the non-diagnostic rate for the 25-G needle was 34.97%, which was significantly lower than 58.13% in all the 22 G groups. For the solid and mixed nodules, the non-diagnostic rate was lower in the 25-G needle group compared to the 22 G groups with statistical significance. The non-aspiration method using a 25-G needle with multiple passes can result in a higher diagnostic rate for thyroid FNA.

Telecytopathology facilitates the use of rapid on-site evaluation in endoscopic ultraound fine needle aspiration of the pancreas to improve patient outcomes

Telecytopathology (TCP) has a variety of different applications in clinical practice and is becoming more widely utilized. Potential uses are broad and include second opinion consultation, primary diagnosis, educational/tumor board, and immediate fine-needle aspiration (FNA) interpretation. More recently, TCP use has been increasingly applied to the immediate evaluation of FNA biopsy adequacy evaluation. This process is generally known as rapid on-site evaluation (ROSE). Khurana et al. reported their findings using TCP for ROSE in endoscopic ultrasound (EUS) FNA of the pancreas.[1] They separated 217 patients into two cohorts. One cohort had on-site evaluation performed by a cytopathologist utilizing TCP. The other cohort did not have on-site evaluation. The TCP system utilized a commercially available passive live video from the microscope, obtained at the point of care (EUS gastrointestinal suite) and delivered to the attending cytopathologist in their office at a remote location. A cytotechnologist at the point of care operated the microscope. This was a retrospective study and the decision for ROSE versus non-ROSE was made by the gastroenterologist performing the endoscopy. Based on the on-site evaluation, it was possible for the TCP ROSE cohort to have additional passes performed, as deemed necessary for diagnosis. The majority of solid lesions were selected for TCP ROSE, and the majority of cystic lesions were not selected for TCP ROSE. The authors examined a variety of individual data points, including the nature of the lesion being evaluated (solid vs. cystic) and the diagnostic rates. The four major diagnostic categories included: (1) Nondiagnostic, (2) negative/benign, (3) atypical/suspicious, and (4) malignant. In solid lesions, the percentages for negative/benign and atypical/suspicious were similar in each cohort. Use of TCP ROSE favored solid lesions and had a nondiagnostic rate of 3.7% in comparison to a 25.6% nondiagnostic rate in the solid lesions without immediate evaluation. There was no statistical difference in nondiagnostic rates for cystic lesions between the two groups, although most did not have TCP ROSE (79/93). For all patients, after using multivariate logistic regression, the odds of a nondiagnostic sample were 6.9 times greater without the use of TCP ROSE.

Is endoscopic ultrasonography-guided fine needle aspiration trailblazing in tissue sampling of adrenal masses?

Is endoscopic ultrasonography-guided fine needle aspiration trailblazing in tissue sampling of adrenal masses?

Patient and Tumor Characteristics can Predict Nondiagnostic Renal Mass Biopsy Findings

Identification of patient and tumor characteristics associated with nondiagnostic biopsies is necessary to improve prebiopsy counseling and patient selection. We reviewed the clinical records and prebiopsy imaging of all patients treated with percutaneous biopsy for a renal mass 7 cm or less. Univariate and multivariate logistic regression models were constructed to examine the association between biopsy outcome and clinical/radiographic features. A total of 565 biopsies of renal tumors 7 cm or less in 525 patients were included in the study. There was no significant difference in age, body mass index, Charlson comorbidity score or gender between the patient cohorts with diagnostic and nondiagnostic biopsy. In 83 of 565 patients (14.7%) overall and in 72 of the 413 (17.4%) with a mass of 4 cm or less the biopsy findings were nondiagnostic. Overall 14.7% of masses were cystic and 85.3% were solid with a median tumor size of 2.75 cm (IQR 2.05-4.25). Independent predictors of nondiagnostic biopsy included cystic features, enhancement less than 20 HU, left tumor, tumor diameter and skin-to-tumor distance. The nondiagnostic rate of repeat biopsies was 20.8%, which did not statistically differ from the nondiagnostic rate at the initial renal mass biopsy attempt. Radiologist or pathologist experience was not associated with the biopsy nondiagnostic rate. In 7 of 565 patients (1.2%) hospital admission was required for adverse events after biopsy. Nondiagnostic renal mass biopsies are more common in cystic, nonenhancing, small masses when patients have a skin-to-tumor distance of 13 cm or greater. Excluding patients with these criteria decreased the nondiagnostic rate from 14.7% to 8.7%.

Diagnostic investigation of parotid neoplasms: a 16-year experience of freehand fine needle aspiration cytology and ultrasound-guided core needle biopsy

This study aimed to examine the diagnostic yield of fine needle aspiration cytology (FNAC) and ultrasound-guided core needle biopsy (USCB) in the diagnosis of parotid neoplasia. A 16-year retrospective analysis was performed of patients entered into our pathology database with a final diagnosis of parotid neoplasia. FNAC and USCB data were compared to surgical excision where available. One hundred and twenty FNAC, 313 USCB, and 259 surgical specimens were analyzed from 397 patients. Fifty-six percent of FNAC and 4% of USCB were non-diagnostic. One hundred and thirty-two (33%) patients had a final diagnosis made by USCB and did not undergo surgery. Surgery was performed in 257 (65%) patients, 226 (88%) of whom had a preoperative biopsy. Most lesions were benign, but there were 62 parotid and 13 haematological malignancies diagnosed; false-negative results were obtained in three FNAC and two USCB samples. The sensitivity and specificity of FNAC were 70% and 89%, respectively, and for USCB were 93% and 100%, respectively. This study represents the largest series of patients with a parotid neoplasm undergoing USCB for diagnosis. USCB is highly accurate with a low non-diagnostic rate and should be considered an integral part of parotid assessment.

Utility of liquid-based cytologic examination of distal esophageal brushings in the management of Barrett esophagus: a prospective study of 45 cases

The goal of Barrett esophagus surveillance is to identify high-grade dysplasia (HGD) for eradication. Surveillance programs currently rely on limited histologic sampling; however, the role of cytology in this setting is not well studied. From December 1, 2011 to March 30, 2014, 45 patients underwent 4 circumferential brushings of the distal tubular esophagus followed by standard 4-quadrant biopsies. One ThinPrep slide and 1 Cellient cellblock (Hologic, Boxborough, Mass) were prepared. Six cytopathologists evaluated each for adequacy, intestinal metaplasia (IM) and dysplasia. Findings were classified using the traditional 5-tier system used for biopsies. A prospectively modified 3-tier cytologic classification was also tested: negative for HGD, indeterminate for HGD, and HGD. Sensitivity, specificity, and kappa values (interobserver agreement) for cytology were calculated. Ten of 45 patients had nondiagnostic cytologies; none of whom had dysplasia on biopsy. Cytology had good sensitivity (82%) and specificity (88%) for identifying IM compared with biopsy with moderate interobserver agreement (pairwise average of Fleiss and Krippendorf kappa value = 0.589, 79% agreement). One case had IM on cytology not detected on histology. Six of 45 patients had dysplasia on biopsy including 1 intramucosal adenocarcinoma, 1 indeterminate for dysplasia, 2 high-grade dysplasias, and 2 low-grade dysplasias. A non-negative adequate cytology sample had a sensitivity of 100% and a specificity of 88% and 94% for the 5-tier and the 3-tier classification, respectively. Cytology appears to have good sensitivity and specificity for diagnosis of HGD, and cytology may be poised to synergize with advances in other techniques for management of patients with Barrett esophagus. Improvements in brushing devices may help to decrease the nondiagnostic rate.

Neuroendocrine Cell Hyperplasia: A Diagnostic Pitfall in Pancreas Cytopathology

cance of indeterminate cytologic diagnoses in ductal lesions, there is a relative lack of knowledge on the importance of indeterminate diagnoses when dealing with PanNETs. Materials and Methods: The pathology records of a large tertiary care center were searched for FNA specimens of pancreatic lesions with documented histologic diagnosis of PanNET. Cytopathologic diagnoses were categorized according to their index of suspicion (atypical, suspicious for PanNET and PanNET). Additionally, the exact reasons for the various indeterminate categories were investigated (qualitative and/or quantitative lack of cytologic features, lack of confirmatory immunocytochemistry ICC). Results: One hundred and fifteen (115) cases of PanNET were identified. Of these, 50% (58/115) were diagnosed as PanNET, 8% (9/115) were suspicious for PanNET, 18% (21/115) were atypical, NOS, 6% (7/115) did not sample the lesion and were called benign and 17% (20/115) were nondiagnostic. Of those 58 cases that were definitively malignant, 43 (75%) required ICC for the diagnosis. Not surprisingly, all 30 indeterminate cases were morphologically suggestive of PanNET but did not have sufficient material for confirmatory ICC. The relative lack of diagnostic material was a significant impediment in almost a quarter of the resected PanNETs not achieving an adequate sampling of the tumor. Conclusions: FNA has a low sensitivity for a definitive diagnosis of PanNET (50%). The incidence of an indeterminate diagnosis (suspicious/ atypical) is high (26%) as well as non-diagnostic rate (17%). ICC is commonly employed to confirm cytologic interpretations (75% of the time). The common reasons for indeterminate diagnoses were e quantitative lack of lesional cells, abundant diluting benign acinar tissue, lack of welldeveloped neuroendocrine features and lack of material for confirmatory ICC.

Predictors of Nondiagnostic Cytology in Surgeon‐Performed Fine‐Needle Aspiration Biopsy of Thyroid Nodules

Objectives: (1) List the factors that are predictive of non-diagnostic cytology in surgeon-performed ultrasound-guided fine-needle aspiration (FNA) of thyroid nodules. (2) Describe a patient cohort that may benefit from early referral to other clinicians. Methods: Retrospective chart review. Patients included all adults who underwent thyroid nodule FNA by a staff, fellow, or resident otolaryngologist at our center between January 2011 and June 2013. Cytology was interpreted by a staff cytopathologist according to the Bethesda classification system. The predictive factors analyzed were patient age, sex, body mass index (BMI), thyroid gland size, thyroid function, presence of multinodular goiter, presence of Graves’ disease or thyroiditis, nodule size, location, vascularity, echogenicity, calcifications, cystic component, level of performer training, and level of FNA experience. Results were analyzed using chi-squared, Fisher exact test, or unpaired t test. Results: A total of 190 patients were reviewed, for a total of 301 nodules. The average age was 53 years, with an 88% female predominance. The overall nondiagnostic rate was 23%. Nodules with a predominant cystic component and those less than 1 cm were more likely to yield nondiagnostic cytology ( P = .04, P = .05, respectively). FNA performed by a trainee with experience of less than 50 FNA were also more likely to yield nondiagnostic cytology ( P = .04). No other factors significantly influenced the nondiagnostic rate. Conclusions: Cystic nodules and nodules less than 1 cm are more likely to yield non-diagnostic cytology in surgeon-performed thyroid FNA. Caution should be used in trainee-performed FNA for which the nondiagnostic risk is high. These patients may benefit from early referral to other clinicians.

Percutaneous renal tumour biopsy

The use of percutaneous renal tumour biopsy (RTB) as a diagnostic tool for the histological characterization of renal masses has increased dramatically within the last 30 years. This increased utilization has paralleled advances in imaging techniques and an evolving knowledge of the clinical value of nephron sparing surgery. Improved biopsy techniques using image guidance, coupled with the use of smaller gauge needles has led to a decrease in complication rates. Reports from series containing a large number of cases have shown the non-diagnostic rate of RTB to range from 4% to 21%. Re-biopsy has been shown to reduce this rate, while the use of molecular markers further improves diagnostic sensitivity. In parallel with refinements of the biopsy procedure, there has been a rapid expansion in our understanding of the complexity of renal cell neoplasia. The 2013 Vancouver Classification is the current classification for renal tumours, and contains five additional entities recognized as novel forms of renal malignancy. The diagnosis of tumour morphotype on RTB is usually achievable on routine histology; however, immunohistochemical studies may be of assistance in difficult cases. The morphology of the main tumour subtypes, based upon the Vancouver Classification, is described and differentiating features are discussed.

Prospective evaluation of impact of using the Bethesda System for Reporting Thyroid Cytopathology: an institutional experience

The Bethesda System for Reporting Thyroid Cytology (BSRTC) refines the definition of and provides specific diagnostic criteria for fine-needle aspiration (FNA) assessment of thyroid lesions. This study was conducted to prospectively evaluate the diagnostic and clinical impact of using BSRTC for management of thyroid lesions and to compare diagnostic performance of post-BSRTC period with that of pre-BSRTC period. The study included FNA specimens obtained in our institution 2.5 years prior to and 2.5 years after implementing BSRTC. Nondiagnostic rate, distribution of the diagnostic categories, rate of surgical follow-up, cytohistologic concordant rate, and risk of malignancy were calculated and compared between pre- and post-BSRTC periods. In comparison to the pre-BSRTC period, the post-BSRTC period generated a lower nondiagnostic rate (19.9% versus 15.8%), a greater proportion of benign (65.3% versus 69.2%) and atypia of undetermined significance or follicular lesion of undetermined significance (4.4% versus 7.4%) in contrast with a decreased proportion of follicular neoplasm or suspicious for follicular neoplasm categories (5.6% versus 2.2%). Rate of surgical follow-up decreased for benign (13.8% versus 7.6%) and atypia of undetermined significance or follicular lesion of undetermined significance (61.5% versus 42.1%) categories, and overall surgical rate reduced (24.2% versus 18.1%). Implementation of BSRTC did not affect overall rate of cytohistologic concordance (78.4% versus 80.5%) or the overall rate of histologically proven malignancy (30.6 versus 36.9%), whereas the individual cytohistologic concordant rate and the malignant rate for each of the diagnostic categories did not differ between pre- and post-BSRTC. The implementation of BSRTC resulted in a decreased overall surgical rate, particularly for benign and follicular lesion of undetermined significance categories, without affecting overall cytohistologic concordance and rate of malignancy.

Telecytopathology for on-site adequacy evaluation decreases the nondiagnostic rate in endoscopic ultrasound-guided fine-needle aspiration of pancreatic lesions.

Advances in digital imaging methods have resulted in use of telecytology in the immediate assessment of fine-needle aspiration (FNA) specimens. We retrospectively compared the nondiagnostic rate for endoscopic ultrasound-guided (EUS) FNA of pancreatic lesions in two groups: one with on-site evaluation for adequacy via telecytopathology and the other without on-site adequacy evaluation. All patients undergoing EUS-FNA of pancreatic lesions over a 2-year period were included. Direct smears were immediately wet-fixed or air-dried, and any residual material was rinsed in saline for cell block or cytospin preparation. Patients were divided into two groups: Group 1 had on-site telecytopathology evaluation for adequacy by a cytopathologist, and Group 2 had no on-site adequacy evaluation. The cytologic diagnoses were reviewed, and the nondiagnostic rates for each group were calculated. The age, sex, and characteristics of pancreatic lesions (solid versus cystic) between the two groups were compared. In total, 217 patients were included. Telecytopathology on-site evaluation was provided for 95 (43.8%) cases. There was no difference between the groups in terms of age and sex. Pancreatic lesions were predominantly solid in the group that underwent telecytopathology on-site evaluation (p<0.005). The nondiagnostic rates for solid lesions in Group 1 and Group 2 were 3.7% and 25.6%, respectively (p<0.0001). Although the nondiagnostic rate for cystic lesion was higher in Group 2, it did not reach a level of statistical significance (16.5% versus 7.1%; p=0.249). After adjusting for the effects of sex and lesion characteristics (solid versus cystic lesion) with multivariate logistic regression, the odds of having a nondiagnostic specimen in Group 2 was 6.9 times greater than in Group 1, and the result was statistically significant (p=0.0013). Telecytopathology on-site evaluation of EUS-FNA of pancreatic lesions reduces the nondiagnostic rate, especially in lesions with solid characteristics, and may serve as an effective substitute for on-site evaluation by a cytopathologist.

The impact of atypia/follicular lesion of undetermined significance and repeat fine-needle aspiration: 5 years before and after implementation of the Bethesda System.

Limited studies have examined the impact of the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) and specifically the category of atypia or follicular lesion of undetermined significance (AUS/FLUS). We studied their effects on reporting rates, subsequent management, and surgical outcome over a 10-year period, 5 years before and after implementation of the BSRTC. A retrospective review of thyroid fine-needle aspiration (FNA) reports from 2003 to 2012 was performed. Diagnoses made before BSRTC were reclassified into the most appropriate category. Repeat FNA results for all AUS/FLUS cases were recorded. Surgical follow-up results were matched by side and size of the targeted nodule. Incidental microcarcinomas were not considered "malignant" on excision. Malignancy rates were calculated based on excision and by all aspirated specimens. Initial AUS/FLUS cases increased from 3% to 7% (P = .001) with implementation of the BSRTC. The nondiagnostic rate decreased from 19% to 10% (P = .026). Differences in malignancy rates before and after implementation of the BSRTC were not significant for all diagnostic categories. More repeat FNAs and fewer surgical excisions were performed after an initial AUS/FLUS diagnosis. Repeat FNA reclassified 56% of AUS/FLUS cases into a definitive category. The malignancy risks for AUS/FLUS plus benign and AUS/FLUS plus AUS/FLUS repeat FNAs were elevated compared with single benign and AUS/FLUS diagnoses. AUS/FLUS cases are increasing with the implementation of the BSRTC. Given the potential increase in repeat FNAs as a result, it may be important to alert the clinician regarding the elevated malignancy risk of a benign or AUS/FLUS diagnosis associated with a prior AUS/FLUS finding.

Core needle biopsy can minimise the non-diagnostic results and need for diagnostic surgery in patients with calcified thyroid nodules

To evaluate the role of core needle biopsy (CNB) for calcified thyroid nodules. Between October 2008 and July 2011, 264 patients underwent ultrasound-guided CNB for 272 calcified thyroid nodules at our institution. We retrospectively evaluated the incidence of technical failure, non-diagnostic readings, and the diagnostic performance of CNB, and analysed the relationship between the types of calcification and the CNB results. Finally, the incidence of diagnostic surgery was calculated. The incidence of technical failure was 1.1 % (3/275) and that of non-diagnostic results was 0.7 % (2/272). The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CNB were 94.7 %, 89.5 %, 100 %, 100 %, and 90.2 %, respectively. There were no significant differences according to the calcification subtype for either the non-diagnostic results or the incidence of technical failure (P > 0.99 and P > 0.99). CNB could prevent diagnostic surgery for 92.9 % (13/14) of the patients who showed more than two non-diagnostic results in previous FNA. CNB can minimise the non-diagnostic results as well as diagnostic surgery in patients with calcified thyroid nodules. Therefore, CNB may be used as a first-line diagnostic tool for calcified thyroid nodules rather than FNA. CNB results show the low incidence of technical failure (1.1 %, 3/275). • CNB results show the low non-diagnostic rate (0.7 %, 2/272). There were no significant differences according to the calcification subtype. CNB can prevent unnecessary diagnostic surgery in 92.9 % (13/14).

Predictors of non-diagnostic cytology in surgeon-performed ultrasound guided fine needle aspiration of thyroid nodules.

BackgroundFine needle aspiration (FNA) is the standard of care for the diagnostic work-up of thyroid nodules but despite its proven utility, the non-diagnostic rate for thyroid FNA ranges from 6-36%. A non-diagnostic FNA is problematic for the clinician and patient because it can result in repeated procedures, multiple physician visits, and a delay in definitive treatment. Surgeon-performed FNA has been shown to be safe, cost-effective, as accurate as those performed by other clinicians, and has the added benefit of decreasing wait times to surgery. Several studies have examined rates and factors that may be predictive of a non-diagnostic cytology in non-surgeon FNA, but none have evaluated this in surgeon-performed thyroid FNA. If these factors are unique in surgeon-performed vs. non-surgeon performed thyroid FNA, then patients may be more appropriately triaged to FNA by alternate clinicians.ObjectivesThe purpose of this study was to determine the rate and factors predictive of a non-diagnostic FNA in surgeon performed ultrasound-guided FNA of thyroid nodules.MethodsWe conducted a retrospective review of all adult patients who underwent thyroid FNA by a staff, fellow, or resident Otolaryngologist at the University of Alberta between January 2011 and June 2013. Factors analyzed included patient factors, thyroid characteristics, nodule characteristics, and surgeon level of training and experience. Univariate and multivariate binary logistic regression analysis were performed.Results131 patients (180 nodules) were reviewed. The non-diagnostic rate was 23%. Nodules with predominant cystic component, those less than 1 cm, and resident-performed FNA were associated with non-diagnostic cytology (p = 0.001, p = 0.02, p = 0.04 respectively). A cystic nodule was the only independent predictor of non-diagnostic FNA on multivariate analysis (OR = 4.441, 95% CI [1.785-11.045], p = 0.001).ConclusionsThe rate of non-diagnostic thyroid FNA performed by a surgeon with ultrasound guidance is similar to other clinicians. A cystic nodule is a strong independent predictor of non-diagnostic cytology. Non-cystic nodules may particularly benefit from surgeon-performed thyroid FNA due to the high diagnostic rate and potential for earlier definitive management.